367700110-9-28-2023-12-CC-JTAO-CW4S39-20230928133045

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 367700110
Report Date: 09/28/2023
Date Signed: 09/28/2023 01:30:54 PM

Document Has Been Signed on 09/28/2023 01:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME:	HOLGUIN FAMILY CHILD CARE		FACILITY NUMBER:	367700110
ADMINISTRATOR:	HOLGUIN, TINAMARIE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(909) 910-3009
CITY:	APPLE VALLEY	STATE: CA	ZIP CODE:	92307
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 7	DATE:	09/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:37 AM
MET WITH:	Tinamarie Holguin, Licensee		TIME COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 09/28/23, Licensing Program Analyst (LPA) Justeene Tamayo met with Licensee Tinamarie Holguin, who guided analyst on a tour of the facility for the One Year Required inspection. This is a one story, 3 bedroom, 2 bathroom home with kitchen/dining, living room, laundry room and attached garage. There is no pool/spa or body of water on the premises. Upon arrival LPA observed 3 infants, and 4 preschool children in care, along with assistant #1. Family members residing in the home include 2 adults (licensee and licensee's husband) and 1 minor children. Facility operation are Monday-Friday 7AM-5PM. Incidental Medical Services (IMS) policy was discussed. Physical Plant: Main care is provided in the living room. Children use the bathroom in hallway on the right. Children have access to the living room and backyard. Off limit areas include all bedrooms, bathrooms #2, laundry room, and garage. LPA observed the main care area to be fully barricaded by a safety gates. The home was inspected inside and out for safety, clean and orderly, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents/cleaning compounds (under kitchen sink with safety latch), medicines (garage off limits-with key lock) and hazardous items (sharp knives in upper kitchen cabinet unreachable to children in care) that can pose a danger to children. LPA observed a fireplace in the the living room to be fully barricaded. Safe and age appropriate toys, play equipment and materials were observed. The smoke detector and carbon monoxide detector, Fire Extinguisher (2A10BC) are in operable condition. Per Licensee no one smokes in the home. Electrical outlets are inaccessible. LPA reminded licensee, no baby bouncers saucer chairs, or any recalled and or prohibited toys or sleep/ play equipment are allowed. There is a designated area for ill children as necessary in living room near the kitchen area. Per Licensee there are no weapon/firearms in the home. The facility sketch is complete and current, there is working telephone (cell).

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Justeene Tamayo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: HOLGUIN FAMILY CHILD CARE	FACILITY NUMBER: 367700110
	VISIT DATE: 09/28/2023

NARRATIVE

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Fire/Disaster Drill is complete and maintained current. Last Fire/Disaster Drill was completed on 09/01/23.

Roster complete and maintained current.

Bathroom: Shower/tub are free of hazards (child care bathroom). LPA did not observe any hazardous items in the children's bathroom. Toilet and faucet are clean and operable.

Kitchen: Sharp utensils, open bottles or alcohol are inaccessible. If food is brought from the children’s home, the container shall be labeled with the child’s name and properly stored or refrigerated. The home has a clean and fully stocked refrigerator/freezer. Cleaning supplies are under the kitchen sink with a safety latch. Licensee currently has a food program. Breakfast, lunch, snacks and dinner are provided. Naps are provided on cots in the living room.

Outdoor: The backyard is safe for children. The backyard is completely fenced (with chain link fence). There is no body of water.LPA observed age appropriate toys. Per licensee, there are two dogs on the premises.

Advisory/Other: First Aid kit was observed with supplies readily available. CPR/First Aid expired 03/27/2023. Licensee will retake her mandated reporter training and send proof of completion to LPA Tamayo no later than 10/12/23. Facility has been cited a Type B Citation-Please see LIC809-D for Deficiency page. Mandated Reporter expires 03/28/2024. There are no window cords accessible to children.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Justeene Tamayo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: HOLGUIN FAMILY CHILD CARE	FACILITY NUMBER: 367700110
	VISIT DATE: 09/28/2023

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Documents Provided and or Discussed: Fire Drill Log, Roster, Postings, Safe Sleep PIN 20-24-CCP, Individual Sleeping Plan (LIC9227), and Safe Sleep Log. Licensee has no children in care during the inspection, however, one file was reviewed for information. Licensee stated currently does not have child care insurance.

Licensee Holguin was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with licensee Holguin and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

A notice of site visit was given to licensee and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee Tinamarie Hulguin, along with her appeal rights and Notice of Site Visit.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Justeene Tamayo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/28/2023 01:30 PM - It Cannot Be Edited

Created By: Justeene Tamayo On 09/28/2023 at 01:14 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: HOLGUIN FAMILY CHILD CARE	FACILITY NUMBER: 367700110
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102416(c)

Personnel Requirements

(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review,, the licensee did not comply with the section cited above. Licensee's CPR/First aid expired on 03/27/2023, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/12/2023
	Plan of Correction
1 2 3 4	Licensee will retake her CPR/First Aid course and send proof of completion to LPA Tamayo no later than 10/12/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Mariela Ramon

LICENSING EVALUATOR NAME:

Justeene Tamayo

LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC809 (FAS) - (06/04)

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